New Client/Patient Survey in Milan, MI | Milan Area Animal Hospital

Milan Area Animal Hospital (MAAH) is currently booking 3 - 4 weeks out for appointments and we are no longer accepting new clients on an emergent basis. Here at MAAH we want to partner with you for your pet(s) healthcare needs. Due to a massive increase in client needs recently, we are no longer able to accept new clients without pre-screening to ensure that we are establishing a good doctor/client relationship. A good veterinary doctor/client relationship is based on honesty, respect and communication. Please fill this form out and return with all previous veterinary history.

CLIENT INFORMATION:

Name*

First Last

Phone*

*

CELL
HOME

Alt Phone:

Alternate Contact

Name:

Relationship:

Phone:

Is pet residing with Primary client?*

Yes
No

If yes, for how long?

Permission for alternate to give consent for procedures and/or medications?*

Yes
No

PATIENT INFORMATION:

Pet Name*

Nickname

Species:*

Canine
Feline
Avian
Rodent
Reptile

Breed

Age*

Sex*

Spayed/Neutered*

Yes
No

At what age was pet spayed/neutered?*

What is your pets normal diet?

Is this pet kept current on:

Vaccinations (Distemper, Rabies, etc.)*

Yes
No

If not current, when was the last time given?

Yearly Blood work (Chemistries & CBC)*

Yes
No

If not current, when was the last time done?

Heartworm Testing*

Yes
No

If not current, when was the last time done?

Testing for Tick-Borne Diseases (inc Lyme)

Yes
No

If not current, when was the last time done?

Fecal tests*

Yes
No

How often is testing done?

Every 6 Months
Yearly

If not current, when was the last time done?

Is your pet on heart-worm prevention?*

Yes
No

If yes, which one

Do you keep your pet on this prevention year round?

Yes
No

Is your pet on flea & tick prevention?*

Yes
No

If yes, which one

Do you keep your pet on this prevention year round

Yes
No

Is your pet on any other medications? (Please list medication, frequency, and condition being treated)

Does your pet have a Chronic medical condition?

Yes
No

If yes, describe below

Does your pet reside*

Inside
Outdoors
Both

Does your pet have any behavioral problems that you are concerned with?*

Yes
No

If yes, explain

I hereby agree that the information provided is true and precise, to the best of my knowledge.

Signature*

Date*

Medical Records

Drop files here or

Did you have your records sent to our office at 734-439-0556? If not, please upload records at this time.